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Student Biodata Fillable

Student Biodata Fillable

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Published by: aravindmalkaji on Aug 24, 2010
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08/20/2013

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Student Participants
International Education Bio-Data Form for International Field Experience
Personal Information (Print Clearly)
CSUID: Name:
First MI Last

(Please attach photo of yourself with face approx. 1” long; may be any type of picture.)

International Education 1024 Campus Delivery Fort Collins, CO 80523-1024 Tel.(970) 491-5917 Fax (970) 491-5501 http://www.international.colostate.edu/ intled@colostate.edu

Academic Information
Class Standing:  Undergraduate  Freshman  Junior  Masters  Ph.D.  Sophomore  Senior

Date of Birth:
Month

/
Day

/
Year

Expected Graduation Date: MO Major: Minor:

YR

Marital Status: Single Gender:

Married Male

Other Female

Ethnicity: Mark all that apply (disclosure is voluntary and will not be used in a
discriminatory manner).

American Indian or Alaska Native White, not of Hispanic origin Asian Black, African American, not of Hispanic origin Hispanic Native Hawaiian or Other Pacific Islander I do not wish to provide this information Country of Citizenship: Passport Number: Date Issued: Expiration Date: _____________________ Local Home Address:

CSU Program Information
Sponsoring Department: Host Country: Host City(ies): Dates of Program From: To:

International Student ID Card Information
*Remember to activate your card online to receive your benefits*

ISIC Number: ISIC Expiration Date:

Perma

Health Considerations
Please read and initial the following statement: The stress of travel and adjusting to a new culture can exacerbate physical or psychological conditions that may be under control at home. If you are currently receiving treatment, or have received treatment in the past, it is important that you share this information with your program advisor and that you meet with your physician or counselor to discuss how international work and travel could affect your medical condition. You may consult your personal physician, the County Health Dept. travel clinic, or Hartshorn Health Center for your travel consultation. I understand that I am responsible for consulting my physician and getting all necessary immunizations and staying on medications recommended for my travel abroad.

Permanent Home Address:

Cell/Local Phone: ______________________________________ Email: ________________________________________________ Important! You are responsible for notifying International Education in writing within 10-days of any change in address, phone or email (intled@colostate.edu).

Initials:
Continue on next page…

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complete this for the period of time since you have enrolled at CSU: Have you been convicted of a misdemeanor? Have you been convicted of a felony? yes no yes no This consent will remain in effect for three years from the date of signature unless I provide International Programs with a written revocation of this consent.edu/policies. I agree to assume financial responsibility for the program fees and for my own welfare while abroad. I understand that as a participant in the program abroad I shall be subject to certain rules and requirements of this University and of cooperating organizations. 3. Information regarding your program abroad. with your biodata. marked confidential. Do Not release any information Name 1. Relationship Phone Number Background Check Your participation in the program abroad may require a legal background clearance. Signature Signature Date Page 2 of 2 Date . if required. and I agree to abide by all rules and regulations that pertain to students and/or employees of Colorado State University. Information in the event of a legal and/or disciplinary situation abroad. As a participant. which I agree to fulfill in all respects. newspapers. Agreement: I certify that the information submitted on this form as given above is true and complete. program. alter or amend any part of any program or to increase charges should circumstances make these actions advisable or necessary.Releases: Please Complete and Sign Photo release Occasionally IFE participants may be photographed in program activities for use in International Education documentation and marketing. Have you been on probation or done court ordered community service? yes no Are any disciplinary actions pending at CSU? yes no Required Signature Date If you have answered yes to any of these questions. If you are a CSU student. Signature: I am participating in this program voluntarily. 2.studentaffairs.aspx and to follow instructions and guidelines from the group leader(s)for the duration of the program. as described in the CSU Student Conduct Code http://www. for the purpose of keeping these person(s) advised of my health. subject to immediate dismissal from the program if I do not do so. you must provide permission for us to do so in writing. May we take your picture for program documentation and marketing purposes? Emergency Contact Information 1: Contact Name: Relationship to you: Address: Home Phone: Work or Cell Phone: E-Mail: Yes No Initials FERPA Release (Family Educational Rights and Privacy Act) If you wish for the Office of International Programs to be able to discuss any of the topics listed below with other designated individuals. This will be kept confidential. I give my consent to the Office of International Programs at Colorado State University to release the following personally identifiable information from my education record to the person(s) listed below. you will be responsible for paying this fee. I understand that the International Education reserves the right to cancel. on web sites and in other marketing and impact reports. Emergency Contact Information 2: Contact Name: Relationship to you: Address: Home Phone: Work or Cell Phone: E-Mail: (Initial all that apply): Health information in the event that the Office of International Programs is notified of a serious physical or mental health condition or emergency. The Colorado State University Police Department will perform or refer you to an organization that will do a background check for a fee. please attach a letter of explanation in a sealed envelope. and/or safety while I am abroad. Photographs may be used in newsletters.colostate.

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